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The past 24 hours of Graham-Cassidy, explained

Lindsey Graham Bill Cassidy Alex Wong / Getty Images
Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

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This was the state of play on Obamacare repeal by mid-afternoon on Monday: We were getting ready for a pointless hearing on a dying bill while waiting for an outdated CBO score.

It's a helluva way to reform a health care system.

There has been a lot of motion but not a lot of meaningful movement on Graham-Cassidy over the past 24 hours. Let's break it down into digestible pieces:

1) Graham and Cassidy are tweaking the bill to win votes.

We got a revised bill last night. The big changes:

  • Deeper deregulation of the insurance market, which certainly undermines the current protections for people with preexisting conditions. Choice quote from Vanderbilt University's John Graves: “Amounts to launching a cannonball into the insurance pool and then claiming it won’t cause a splash or make anyone wet.”
  • Targeted funding increases to states including Alaska (where Sen. Lisa Murkowski is still a key vote) and Louisiana (Sen. Cassidy's home state, as CNN's Lauren Fox flagged).

But the core of the bill is still block grants and Medicaid per capita caps, which outside estimates say would lead to a $215 billion federal spending cut and 21 million fewer Americans with health insurance when compared to Obamacare.

2) Graham-Cassidy is still short on votes.

But despite the revisions, the bill doesn't seem to have made any political headway. Remember: There are 52 Senate Republicans, and 50 of them must back the bill for it to pass.

  • Arizona Sen. John McCain is a "no" over process and partisanship. No reason to think he's going to change his mind.
  • Maine Sen. Susan Collins said Sunday she was likely a "no," and given that her concerns have been over preexisting conditions and Medicaid cuts, her position does not look likely to change.
  • Kentucky Sen. Rand Paul reiterated he was a "no" on the bill. His path to "yes"? Eliminate the block grants that are the core of the bill. That's all.
  • Sen. Ted Cruz's staff also told reporters that while the Texas senator wantsto get to "yes," he is still a "no" for now. Most lobbyists don't take Cruz's objections too seriously, but it really doesn't help the whip count.

That doesn't include Murkowski, who has opposed every repeal bill so far.

3) Republicans aren't being straight about what the bill would do.

If you haven't yet, watch this video from today's Senate Finance hearing, as a protester is dragged out of the room objecting to Medicaid cuts. It's a stark reminder of the deep opposition to this bill, from patient groups, from doctors, from hospitals.

Since then, the hearing hasn't featured much drama. But there were a couple of moments that stuck out to me, when key arguments for and against the bill popped up.

Argument 1: Cassidy said states can continue Medicaid expansion if they want.

The bill actually repeals the Medicaid expansion eligibility, which means a state would have to apply again to the federal government in order to restart its expansion. Experts aren't sure whether a state could actually get a waiver approved, given the budget neutrality requirements that come with Medicaid waivers.

But more fundamentally, the block grant formula cuts funding for Medicaid expansion states. It's hard to see how they could then make the math work, without ponying up an impractical amount of money themselves or cutting assistance for middle-class people who buy private coverage.

This is why experts say the bill's funding cuts would inevitably lead to fewer people with coverage.

"The state ... could try to use block grant funds to set up a Medicaid-like program for the former expansion population outside Medicaid proper," Matt Fiedler at the Brookings Institution told me. "But that ultimately runs into the problem that there’s just not enough money in the block grant to ensure that everyone who has coverage today can keep it."

Argument 2: Cassidy said HHS can punish states that don't protect preexisting conditions.

This is a big issue. Experts say that while the bill nominally requires states that waive Obamacare's regulations to explain how they'll provide affordable and adequate coverage to people with high medical costs, experts have said that the federal government's ability to enforce the requirement is weak.

Cassidy told the committee that HHS could either 1) deny an application to waive the insurance regulations or 2) pull back dollars later if a state fails to comply. I asked Fiedler if that was true.

He responded:

My view is that both enforcement tools are fairly weak. The ability to use tool No. 1 is limited by the complete lack of concrete criteria on what constitutes “adequate and affordable” coverage. In particular, it’s not clear how much the administration could look behind a state’s assertions in this area. And tool No. 2 is probably only usable in a case where a state says one thing in its application and actually does another; it’s likely not enough for the state’s plan to simply fail to work as intended.

I wanted to show the whole explanation, but in short, it is far from the guaranteed protections that Obamacare currently provides.

4) Republicans want to present the debate as either Graham-Cassidy or Bernie Sanders's single-payer health care. It's not.

Cassidy said during the hearing that bipartisan talks didn't happen after Obamacare repeal failed in July. Senate Majority Leader Mitch McConnell echoed this notion on Twitter, saying Democrats want to either do nothing or impose Medicare-for-all.

That's simply not true.

Whatever you think of the ideas, however narrow the talks that Sens. Lamar Alexander (R-TN) and Patty Murray (D-WA) engaged in were, there was a clear outline for a short-term package to stabilize Obamacare.

Those talks were scuttled only after Republican leaders decided Graham-Cassidy had a real shot and wanted to make good on their last chance (for the time being) to deliver on the promise to repeal Obamacare.

You'll see this dynamic again during tonight's CNN debate between Graham, Cassidy, Sanders and Sen. Amy Klobuchar (D-MN): repeal or single-payer.

The truth is that there is some room for bipartisan work on health care. We've seen the outline. But it's likely impossible for as long as Obamacare repeal is still alive, however tenuously.

Quote of the Day

There’s not an actual human constituency for any aspect of the Republican congressional agenda. Instead it’s an inside game that is judged, win or lose, on the basis of which entrenched permanent interests gain advantage or disadvantage, and how that affects the endless fundraising process.

That's what Steve Schmidt, who ran McCain's presidential campaign in 2008, told Vox's Andrew Prokop, making the point that Republican donors, not any real policy, is motivating this last mad dash for Obamacare repeal.

Kliff’s Notes

With research help from Caitlin Davis

Today's top news

  • "Senators Revise Health Bill in Last-Ditch Effort to Win Votes": “With time running short, the authors of the latest plan to repeal and replace the Affordable Care Act shifted money in the bill to Alaska and Maine, which are represented by Republican senators who appear reluctant to support it.” —Robert Pear and Thomas Kaplan, New York Times
  • "Republicans brace for failure on Obamacare repeal": “Republicans in the Senate and White House are increasingly resigned to defeat in their final bid to repeal Obamacare this week, despite a flurry of last-second revisions meant to win over skeptical senators.” —Burgess Everett and Josh Dawsey, Politico
  • "Protesters' chanting sends Obamacare overhaul hearing into recess": “Protesters of the Republican bill to overhaul Obamacare delayed the start of the sole hearing on the bill Monday. 'No cuts to Medicaid, save our liberties,' shouted members of the crowd who were able to make it into the hearing room. Several people were removed from the room, some of them in wheelchairs.” —Robert King and Kimberly Leonard, Washington Examiner

Analysis and longer reads

  • "Biggest Flash Points In The Graham-Cassidy Health Care Bill": “If Senate Republicans vote to repeal and replace the Affordable Care Act this week, it would affect the health care of pretty much every American. Here's a recap of four key flash points in the health overhaul debate with links to NPR coverage over the past six months, and our chart laying out how the Graham-Cassidy bill under consideration in the Senate addresses those issues compared with the Affordable Care Act.” —Nancy Shute, NPR
  • "Rural Maternity Wards Are Closing, And Women’s Lives Are On The Line": “Nationally, more than half of births are funded by Medicaid, which pays doctors back at a much lower rate than private health insurance plans. In rural areas, that percentage tends to be even higher. Malpractice insurance also plays a role. Family physicians, who often deliver babies in rural areas, face higher malpractice premiums if they offer obstetric services, while hospitals may face low-volume penalties.” —Catherine Pearson and Frank Taylor, Huffington Post
  • to Shut Down During Parts of Enrollment Period for Maintenance“: The Trump administration plans to shut down, a website consumers use to sign up for Affordable Care Act insurance, for 12 hours on nearly every Sunday during the coming ACA enrollment season. The outages, which the administration says are needed for maintenance, will occur from midnight through noon on every Sunday other than Dec. 10.” —Michelle Hackman, Wall Street Journal

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